Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50954(U)
Insurer prevailed
The insurer proved proper fee-schedule reductions and lack of medical necessity, and the provider failed to rebut the peer review. The insurer's professional coder established that the unpaid portions sought in the first, second and fifth causes of action exceeded reimbursement permitted by the workers' compensation fee schedule. For the sixth through eighth causes of action, a sworn peer review supplied a factual basis and medical rationale for lack of medical necessity. The provider's doctor's affidavit neither meaningfully addressed nor sufficiently rebutted those conclusions. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, denying the provider summary judgment on the first, second and fifth causes of action and granting the insurer dismissal of those and the sixth through eighth causes of action.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50946(U)
Insurer prevailed
The insurer proved outstanding verification and proper fee-schedule reductions; a challenge to mailing of payment was unpreserved. Nonreceipt of requested verification rendered the fourth cause of action premature. The insurer's professional coder established proper use of the workers' compensation fee schedule for the second and third causes of action, and the provider raised no triable issue as to those causes or the fourth. The provider's challenge to timely mailing of payment on the first cause of action was raised for the first time on appeal and was not considered. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, denying the provider summary judgment and granting the insurer dismissal of the first through fourth causes of action.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50955(U)
Insurer prevailed
The provider failed to prove the assignor's New York residency and the absence of other available insurance coverage for its MVAIC claim. Coverage was the sole issue at the nonjury trial. Under Insurance Law § 5202 (b), residency proof is a condition precedent to qualified-person status and potential eligibility for no-fault benefits under Insurance Law § 5221 (b) (2). The provider did not establish that MVAIC had received residency proof or that no other coverage was available, and therefore failed to establish its prima facie case under those provisions and Insurance Law § 5208. The Appellate Term, Second Department, reversed the provider's judgment and remitted for dismissal of the complaint, dismissing the separate appeal from the decision under CCA 1702.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50935(U)
Provider prevailed
An EUO rescheduled by mutual agreement before its scheduled date does not constitute a failure to appear. The insurer sought summary judgment based on the assignor's EUO nonappearance, alternatively seeking dismissal of amounts exceeding the workers' compensation fee schedule. Its affidavit showed that the initial EUO had been rescheduled twice by mutual agreement before the scheduled dates. Following Vitality Chiropractic, P.C. v Kemper Ins. Co., the Appellate Term, Second Department, concluded that the insurer had not established nonappearance at both an initial and a follow-up EUO or breach of a coverage condition. It reversed, denied the EUO branch, and remitted for determination of the unresolved fee-schedule branch.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50937(U)
Insurer prevailed
The provider failed to prove that spinal surgery was medically necessary after the insurer rebutted the presumption of necessity. At a nonjury trial, the insurer presented the orthopedist who prepared its peer review, who testified that the surgery was not causally related to the accident. The provider cross-examined that witness but offered no rebuttal witnesses. Giving substantial deference to the trial court's credibility assessment, the Appellate Term, Second Department, found that the provider had not met its ultimate burden of proving medical necessity by a preponderance of the evidence. It affirmed the judgment insofar as appealed from, dismissing the spinal-surgery claim.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50947(U)
Insurer prevailed
The insurer's affidavits established timely IME notices, the assignor's nonappearances and a timely denial on that ground. The president of the retained scheduling company established timely mailing of the scheduling letters, the medical provider designated to perform the IMEs established nonappearance, and the insurer's claims examiner established timely mailing of the denial. That proof demonstrated failure to satisfy a condition precedent to coverage under 11 NYCRR 65-1.1 and Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co. The Appellate Term, Second Department, reversed the order denying the insurer's summary judgment motion and granted dismissal of the provider's complaint.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50948(U)
Provider prevailed
The insurer's summary judgment cross motion based on injuries not arising from a covered incident was denied on appeal. The Appellate Term, Second Department, reversed the order, insofar as appealed from, granting dismissal of the provider's complaint. The insurer's proof did not establish its coverage defense as a matter of law under Central Gen. Hosp. v Chubb Group of Ins. Cos.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50958(U)
Insurer prevailed
The provider's action was premature because requested verification remained outstanding when suit commenced. The insurer established nonreceipt, and the provider did not show that it supplied the verification before commencement. Under 11 NYCRR 65-3.5 (c) and 11 NYCRR 65-3.8 (a), the 30-day period to pay or deny therefore had not begun. The Civil Court had limited the remaining trial issue to receipt of verification, and the provider did not challenge its finding that the insurer was otherwise entitled to judgment. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted the insurer's summary judgment cross motion dismissing the complaint.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50960(U)
Insurer prevailed
The insurer established the assignor's IME nonappearances and timely denials issued upon receipt of the claims. The insurer showed that it mailed letters scheduling an initial and follow-up IME before receiving the claims and that the assignor failed to appear for those examinations. Following Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., the assignor's appearance was a condition precedent to the insurer's liability under the policy. The Appellate Term, Second Department, reversed the order denying the insurer's summary judgment motion and granted the motion dismissing the provider's complaint.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50950(U)
Insurer prevailed
The defendant's summary judgment dismissing the complaint was affirmed on its defense of untimely accident notice or proof of claim. The defense invoked the 30-day notice and 45-day proof requirements of 11 NYCRR 65-2.4 (a), (b) and (c). The Appellate Term, Second Department, relied on the reasons stated in Great Health Care Chiropractic, P.C. v Elrac, Inc.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50949(U)
Insurer prevailed
IME notices from a third party adequately identified the claims processor, and the doctor's affirmation proved nonappearance. The provider argued that letters from a third party did not require attendance because they failed to identify the defendant's claim. The letters expressly identified the defendant's claims processing company, to which the assignor had submitted the NF-2 application. The examining doctor's affirmation also sufficiently established the nonappearances. The Appellate Term, Second Department, affirmed summary judgment dismissing the provider's complaint for assigned no-fault benefits.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50942(U)
Insurer prevailed
The insurer's cross motion for summary judgment was granted on its defense that it had issued no policy covering the accident vehicle. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and dismissed the provider's complaint for assigned no-fault benefits for the reasons stated in TAM Med. Supply Corp. v Omni Indem. Co.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50936(U)
Insurer prevailed
The provider's judgment against MVAIC was reversed on the issue of whether the assignor was a qualified person entitled to no-fault benefits. The Appellate Term, Second Department, relied on the reasons stated in Village Med. Supply, Inc. v MVAIC and remitted for judgment dismissing the complaint. It also dismissed the appeal from the trial decision because no appeal lay under CCA 1702.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50939(U)
Provider prevailed
The insurer's untimely follow-up EUO notice rendered its denial untimely and precluded the nonappearance defense. Although counsel established timely mailing of the initial notice, the follow-up was untimely under 11 NYCRR 65-3.6 (b). The insurer could not rely on 11 NYCRR 65-3.8 (l), which expressly excludes follow-up verification requests. The resulting late denial precluded the asserted defense under 11 NYCRR 65-3.8. The provider's cross motion established its prima facie case. The Appellate Term, Second Department, reversed the order, denied the insurer's summary judgment motion, granted the provider's cross motion and remitted for calculation of statutory interest and assessment of attorney fees under Insurance Law § 5106.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50940(U)
Insurer prevailed
The insurer was entitled to sever claims arising from separate accidents and presenting few, if any, common factual issues. The provider sued for services to eight assignors involved in three accidents. The first, third through fifth and seventh causes of action concerned two accidents and denials based on IME findings of lack of medical necessity and the workers' compensation fee schedule. The second, sixth and eighth causes concerned denials asserting that injuries did not arise from an insured incident. Those distinct defenses supported severance under CPLR 603. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted the insurer's cross motion to sever the first, third through fifth and seventh causes of action.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50941(U)
Provider prevailed
The insurer failed to establish a meritorious IME nonappearance defense or grounds to vacate prejudgment interest. Seeking relief from a default judgment entered after failure to appear at trial, the insurer submitted denial forms dated more than a month before it received the claims. That defect defeated the required showing of a meritorious defense under CPLR 5015 (a) (1), so the court did not determine whether the default was excusable. The insurer's challenge to interest accruing before commencement also failed because it did not establish that it ever mailed denials for the claims. The Appellate Term, Second Department, affirmed denial of vacatur.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50943(U)
Insurer prevailed
The insurer established full payment for acupuncture services under the workers' compensation fee schedule applicable to chiropractors. The provider sought additional assigned no-fault benefits, while the insurer contended that it properly reimbursed the services using the chiropractor schedule. The insurer's proof also established a presumption of timely mailing of the denial forms, defeating the provider's mailing challenge. Following Great Wall Acupuncture, P.C. v Geico Ins. Co., the Appellate Term, Second Department, affirmed summary judgment dismissing the complaint. It declined to consider the provider's remaining argument because it was raised for the first time on appeal.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50944(U)
Insurer prevailed
An order continuing a summary judgment motion pending discovery is not appealable as of right. The Civil Court compelled the provider to produce its owner for a deposition and continued the provider's summary judgment motion pending discovery under CPLR 3212 (f). The Appellate Term, Second Department, dismissed the appeal from the continuance under CCA 1702 (a) (2), because leave had not been granted. It affirmed the order, insofar as reviewed, concluding that the insurer was entitled to depose the provider's owner under CPLR 3101 (a).
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50945(U)
Split result
The insurer failed to prove timely fee-schedule denials or lack of coverage for two claims, but raised a triable coverage issue. Checked boxes adequately identified fee-schedule reductions, and the scheduling company's affidavit proved timely IME notices. For the $290.74 and $210.72 claims, however, the insurer did not establish timely denials permitting its fee-schedule defense. Its coverage evidence also failed to establish that the injuries arose outside an insured incident, although it raised a factual issue defeating the provider's cross motion. The Appellate Term, Second Department, modified the order to deny the insurer summary judgment on those two claims and otherwise affirmed, leaving dismissal of the remaining claims and denial of the provider's cross motion intact.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50952(U)
Provider prevailed
The insurer failed to establish proper mailing of IME notices because the record showed conflicting addresses and no confirmed attorney representation. Its papers stated that scheduling letters were sent to the address on the NF-2 form or supplied by counsel, but the notices used East 107th Street while the denial form listed East 106th Street. Copies sent to an attorney did not cure the defect because nothing showed that the attorney represented the assignor. A receipt presumption requires proof of proper mailing, and the insurer did not establish duly scheduled IMEs. The Appellate Term, Second Department, affirmed denial of the insurer's summary judgment motion dismissing the provider's complaint.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50953(U)
Insurer prevailed
The insurer's submissions established a presumption that its IME nonappearance denials were timely and properly mailed. The provider moved for summary judgment on its assigned no-fault claim, and the insurer cross-moved to dismiss based on the assignor's failure to attend duly scheduled IMEs. The provider's sole appellate argument concerning the cross motion challenged mailing of the denial forms. Applying St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., the Appellate Term, Second Department, rejected that challenge and affirmed the order denying the provider's motion and granting the insurer's cross motion dismissing the complaint.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50957(U)
Provider prevailed
The insurer failed to establish timely mailing of the initial and follow-up EUO scheduling letters. It sought summary judgment dismissing the provider's assigned no-fault claims on the ground that the assignor failed to appear for duly scheduled EUOs, asserting timely and proper denials. Without proof of timely mailing, the insurer did not demonstrate that the EUOs were properly scheduled or that the assignor failed to attend duly scheduled examinations. The Appellate Term, Second Department, reversed the order granting the insurer's motion and denied summary judgment.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50959(U)
Insurer prevailed
The provider failed to show that requested verification was supplied before suit, leaving its action premature. The insurer established nonreceipt in support of its summary judgment motion. The Civil Court, Queens County, denied the motion but limited trial issues under CPLR 3212 (g) to whether the provider properly responded to the verification requests. The provider did not challenge the finding that the insurer was otherwise entitled to judgment, and its opposition did not establish a pre-suit response. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted the insurer summary judgment dismissing the complaint as premature.
Appellate Term, Second Department
Jul 21, 2017
2017 NY Slip Op 50961(U)
Insurer prevailed
The insurer established the assignor's failure to attend duly scheduled IMEs and timely denials based on those nonappearances. Before receiving the claims, the insurer mailed letters scheduling an initial and follow-up IME and demonstrated that the assignor failed to appear. Under Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., attendance was a condition precedent to coverage. The provider raised no triable issue in opposition. The Appellate Term, Second Department, reversed the order denying the insurer's summary judgment motion and granted dismissal of the complaint.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50923(U)
Insurer prevailed
⚠ Not followed by MSB Physical Therapy, P.C. v Nationwide Ins. (2021 NY Slip Op 50750(U))
⚠ Not followed by New Chiropractic Care, P.C. v Nationwide Ins. Co. of N.Y. (2020 NY Slip Op
50652(U))
The defendant's timely mailing of the initial EUO notice tolled its time to pay or deny claims received afterward. Although a later letter was merely a delay letter, the first EUO scheduling letter was timely and properly mailed before receipt of the three disputed claims. The provider's dispute over whether duplicate notices used certified mail or certified mail with return receipt requested did not excuse the assignor's nonappearance; no evidence showed that first-class mailing was insufficient. The defendant also established the assignor's failure to attend the EUOs. The Appellate Term, Second Department, affirmed the order granting the defendant summary judgment dismissing the assigned no-fault complaint.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50925(U)
Insurer prevailed
The provider's action was premature because it had not supplied the insurer's requested verification, including wholesale equipment invoices. The insurer moved for summary judgment dismissing the provider's action for assigned no-fault benefits. In opposition, the provider's owner identified the documents sent in response to the verification requests, but that affidavit established that the requested materials had not all been supplied. Following Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., the Appellate Term, Second Department, affirmed the order granting the insurer's motion and dismissing the complaint as premature.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50922(U)
Provider prevailed
The insurer's EUO defense failed because scheduling was late for some claims and the insurer rescheduled each EUO before its date. For one group of claims, the first EUO scheduling letter was mailed more than 30 days after receipt, making the letters a nullity as to those claims. For the remaining claims, the insurer's advance rescheduling meant that nonappearance on the original dates did not constitute EUO failures. The insurer therefore neither raised a triable issue nor established proper denials based on two missed EUOs. The Appellate Term, Second Department, affirmed the judgment entered upon the grant of the provider's summary judgment motion and denial of the insurer's cross motion.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50927(U)
Insurer prevailed
The defendant's affidavits established timely mailing of the IME scheduling letters and denial of claim form. The provider sought assigned first-party no-fault benefits, and the Civil Court, Queens County, granted summary judgment dismissing the complaint based on the assignor's failure to appear for duly scheduled IMEs. The Appellate Term, Second Department, rejected the provider's challenge to the mailing proof and affirmed the order in the defendant's favor.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50926(U)
Insurer prevailed
The defendant's summary judgment dismissal based on accident-notice and claim-submission deadlines was affirmed. The motion invoked 11 NYCRR 65-2.4 (a), (b) and (c), requiring written accident notice within 30 days and written proof of claim within 45 days after services. The Appellate Term, Second Department, relied on the reasons stated in Great Health Care Chiropractic, P.C. v Elrac, Inc., without independent reasoning.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 27246
Provider prevailed
The insurer failed to establish satisfaction of the provider's judgment through a partial satisfaction of a separate judgment in its favor. After default judgment in the no-fault action, the insurer sought summary judgment or satisfaction based on a declaratory judgment and costs award against the provider. Summary judgment was inappropriate after judgment. CPLR 5020 (c) did not apply; relief required a motion under CPLR 5021 (a) (2), and the insurer did not demonstrate filing of the partial satisfaction under CPLR 5020 (a). The Appellate Term, Second Department, affirmed denial of relief and found no abuse of discretion in refusing an offset, assuming without deciding that Civil Court had jurisdiction to entertain one.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50916(U)
Insurer prevailed
The insurer's cross motion for summary judgment dismissing the complaint based on the provider's EUO nonappearance was granted on appeal. The Appellate Term, Second Department, relied on the reasons stated in Bay LS Med. Supplies, Inc. v Allstate Ins. Co. It reversed the order granting the provider's summary judgment motion and denying the insurer's cross motion, and denied the provider's motion.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50917(U)
Split result
The provider's mailing affidavit raised a factual issue over receipt of verification, defeating the insurer's premature-action defense on summary judgment. The insurer established timely mailing of its initial and follow-up requests and made a prima facie showing that the requested verification had not been received. However, the provider's owner's affidavit created a presumption that the verification had been mailed and received under St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co. A triable issue therefore remained as to whether the action was premature. The Appellate Term, Second Department, modified the order to deny the insurer's cross motion for summary judgment; denial of the provider's motion remained in place.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50918(U)
Provider prevailed
The insurer failed to prove the provider's EUO nonappearance through a person with personal knowledge. The insurer obtained summary judgment dismissing the provider's action for assigned no-fault benefits. In opposition and on appeal, the provider challenged an affirmation from a partner in the law firm retained to conduct the EUOs. Following Alrof, Inc. v Safeco Natl. Ins. Co. and Bright Med. Supply Co. v IDS Prop. & Cas. Ins. Co., the Appellate Term, Second Department, found that the affirmation did not satisfy the insurer's burden of proving nonappearance through someone with personal knowledge. It reversed the order and denied the insurer's motion.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50919(U)
Provider prevailed
The insurer failed to establish timely EUO scheduling and denials, defeating its motion for summary judgment based on nonappearance. The insurer sought dismissal of the provider's assigned no-fault claims, alleging that both the provider and the assignor had failed to appear for duly scheduled EUOs. Its own papers stated that the first scheduling letter sent to the provider was mailed more than 30 days after receipt of the claims. The papers also failed to demonstrate timely denials. The Appellate Term, Second Department, reversed the order granting the insurer's motion and denied summary judgment because the insurer had not established entitlement to dismissal for breach of a coverage condition.
Appellate Term, Second Department
Jul 14, 2017
2017 NY Slip Op 50921(U)
Split result
The insurer's conflicting claim-receipt dates prevented summary judgment on late accident notice, but the provider was compelled to give discovery. The discrepancy prevented proof of timely denials asserting a precludable defense. The provider had neither answered discovery demands nor appeared for an examination before trial and did not oppose the discovery branch. Under CPLR 3101 (a), the requested disclosure was material and necessary to the insurer's fee-schedule defense. The Appellate Term, Second Department, modified the order, denied the insurer's summary judgment cross motion, and granted relief under CPLR 3126 only to compel responses within 60 days and an examination within 30 days thereafter, or an agreed date within 60 days thereafter. The provider's summary judgment motion remained denied.
Trial court, Second Department
Jul 31, 2017
2017 NY Slip Op 51047(U)
Provider prevailed
The insurer's trial witness lacked personal knowledge of the assignor's EUO nonappearances, despite proving timely mailing of the requests. At a bench trial, the parties stipulated that the provider established its prima facie case by timely submitting the bills. The insurer's witness described EUO scheduling procedures and reviewed the file and affirmations from the attorneys assigned to conduct the EUOs. The Civil Court, Kings County, credited the testimony on mailing but found that file review and knowledge of office procedures did not establish personal knowledge of nonappearance. The court awarded judgment to the provider, with statutory interest and attorney fees.
Trial court, First Department
Jul 26, 2017
2017 NY Slip Op 50999(U)
Provider prevailed
The insurer failed to prove that the assignor supplied a false and fraudulent residential address in the insurance application. After a bench trial, the Civil Court, Bronx County, awarded the provider judgment with statutory interest. Although Vehicle and Traffic Law § 313 permits only prospective cancellation, fraudulent procurement may be asserted as a defense against a provider seeking assigned benefits. The application listed Rochester, while the driver's license and accident reports listed Jamaica. The insurer had issued a replacement-vehicle insurance identification card bearing the Jamaica address months before the accident. The documentary record left the assignor's residence when applying uncertain and supplied no evidence of intent. The court therefore declined to find intentional misrepresentation and rejected the defense.
Trial court, Second Department
Jul 24, 2017
2017 NY Slip Op 50977(U)
Split result
An insurer's good-faith showing of possible fraudulent incorporation supported discovery into the provider's ownership, operation and control. The District Court, Suffolk County, compelled management agreements, leases, bank records and corporate tax returns, finding special circumstances for tax disclosure under CPLR 3101. Under Mallela and 11 NYCRR 65-3.16 (a) (12), the defense was not precluded and did not require particularized pleading under CPLR 3016 (b). The court denied dismissal and striking the notice of trial conditioned on meaningful discovery responses, compelled a deposition through a knowledgeable representative chosen by the provider, and prescribed preclusion for noncompliance under CPLR 3126. It rejected as vague the demands for "corporate records" and "other tax records" and denied the provider's protective-order and insurer-deposition requests.
Trial court, Second Department
Jul 20, 2017
2017 NY Slip Op 27272
Provider prevailed
An insurer must provide a good-faith basis for a provider EUO when the provider timely requests an explanation before the scheduled date. The Civil Court, Kings County, granted reargument but adhered to denial of the insurer's summary judgment motions in eight actions. The provider requested objective reasons before the EUOs, and the insurer refused to explain before the provider failed to appear. Under 11 NYCRR 65-3.5 (c), departmental review of insurer standards did not replace a response addressing their application to the provider. A substantive explanation need not disclose all information or be sworn. Whether the insurer had a good-faith basis remained triable; for two assignors' claims, trial would also address whether the provider's objections were timely.
Trial court, Second Department
Jul 6, 2017
2017 NY Slip Op 50978(U)
Provider prevailed
The insurer failed to prove mailing or a reasonable basis for verification demands after the provider supplied available MRI documentation. The District Court, Suffolk County, denied the insurer's summary judgment motion under CPLR 3212 (b), rejecting its showing that outstanding verification rendered the claims premature. The adjuster's affidavit did not sufficiently explain mailing procedures after placement in an outgoing mail bin, and the letters lacked a business-record foundation under CPLR 4518 (a). The provider submitted MRI reports and stated that all available documents had been supplied, establishing reasonable justification under 11 NYCRR 65-3.5 (o). The insurer remained silent in response and failed to establish good reasons for continued verification demands under 11 NYCRR 65-3.2 (c).
